Payment Receipt- SA Ambulance Services membership cover online application
SA Ambulance Service
SA Ambulance Cover Membership form
Please select Health insurance provider.
Type of cover
Type of Cover
*
Family ($192.00)
Single ($96.50)
Pensioner Concession Family ($115.00)
Pensioner Concession Single ($58.00)
ACE Family ($51.50)
ACE single ($25.25)
Ambulance Cover Plus
Please select the cover type first
Main applicant details
MembershipId
MembershipNo
Title
Select
Master
Miss
Mr
Mrs
Ms
Mx
Given Name
Family Name
Birth Date
dd/mm/yyyy format
Gender
M
F
X
Email address
Your receipt will be sent to you on the above provided email address
Check this box if you wish to receive renewal notices via email.- .
Contact No.
Other Contact No.
Residential Address
My Postal Address is different to my Residential
Enter Manually
Extra Detail
Room No., nursing home name etc.
Abode
N/A
UNIT
APARTMENT
ROOM
Abode No
Street No
Street Name
DO NOT ENTER PO BOX DETAILS HERE
Suburb/Town
Postcode
Address No.
Unit/House No.
Postal Address
My Postal Address is different to my Residential
Click Enter Manually to populate non-residential address in the fields provided below i.e., GPO BOX, LOCKED BAG etc.
Enter Manually
Extra Detail
Room No., nursing home name etc.
Abode
N/A
UNIT
APARTMENT
ROOM
CARE PO
CMB
GPO BOX
LOCKED BAG
PO BOX
PRIVATE BAG
RSD
RMB
CPA
Abode/PO Box No
Street No
Street Name
DO NOT ENTER PO BOX DETAILS HERE
Suburb/Town
Postcode
Street No.
PostalStreetNo
PostalStreetQualifier
PostalAdobePrefix
Unit/House No.
Dependants' details
Add Members
MembershipId
Given Name
Family Name
Gender
Birth Date
Fulltime student
Residing at home
PCC/DVA Number
Insurance Details
Health insurance provider
None
AHM
Australian Unity
BUPA
Defence Health
GMHBA
Govt Empl Health Fund
HCF
Health Partners
Manchester Unity
MBF
Medibank Private
NIB
Phoenix
Police Health
Teachers Health
Other
Pension Details
Are you eligible for a pension rate.
Pension No.
*
Note:
The pension concession rate does not apply to health care card or senior card holders
Authorised contact
Would you like to nominate a person who can do changes to your membership details on your behalf?
Title
Select
Master
Miss
Mr
Mrs
Ms
Mx
Given Name
Family Name
Birth Date
dd/mm/yyyy format
Contact Number
Electronic Renewals
Complete the following details to receive renewals via SMS or email
Mobile Number
Email address
Opt out of Electronic Renewals (renewals will be posted)
Payment Details
*
You may also like to make a donation to SA Ambulance Services.To do so, simply indicate the amount below in Donation amount you wish to pay.
Membership amount
Extra amount
Donation amount
Total amount
Please read the terms and conditions that applies to your level of cover.I have read, understood and agree to the
Ambulance Cover terms and conditions
I have read, understood and agree to the
ACE(Ambulance Cover Extras) terms and conditions
Check this box if you want to receive your terms and conditions in large font.
Note:
Please check your membership details carefully before you proceed with payment.
Verification Code* :
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